An Interprofessional Approach to Diabetes Management

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1 Disclosures An Interprofessional Approach to Diabetes Management Principal in DiabetesReframed, LLC. Inventor of U.S. Provisional Patent Application No. 61/585,483 METHODS OF USING A DIABETES CROSS- DISCIPLINARY INDEX TO STAGE DIABETES IN A PATIENT Andrew S. Pumerantz, DO, FACP Assistant Provost for Strategic Initiatives Executive Director, WDI Associate Professor of Internal Medicine Chief, Division of Infectious Disease WesternU/COMP Learning Objectives 1. Outline the challenges faced by interprofessional teams in successfully delivering high-value integrated and coordinated fullcycle care to patients with diabetes. 2. Relate the complex interplay between abnormal glucose and lipid metabolism and inflammatory dysregulation to the complications of poorly controlled diabetes. 3. Justify the restructuring of health care delivery systems to assure closer collaboration between medical and dental clinical teams to better diagnose and manage patients with diabetes and periodontitis. 4. Justify organizing interprofessional diabetes management teams around a core collaborative therapeutic alliance between the patient, a clinical pharmacist, and a PA care coordinator. 5. Justify designing personalized full-cycle diabetes care plans based on a patient's specific disease severity and complexity index profile. 1

2 Complex interplay between abnormal glucose and lipid metabolism and inflammatory dysregulation Multiple organ system complications 2x risk of premature death US spent $201 billion in 2011 Major cost driver: lack of control of the ABCs (HbA1c, BP, and LDL-C) HbA1c 7% risk for hospitalizations and prolonged stay expenditures Care New-patient goals: 1. Detect presence of complications 2. Formulate management plan 3. Provide basis for continuing care cdc.gov ADA Clinical Practice Guidelines. Diabetes Care 2012; 35 (Suppl 1) 2

3 Plan Management should be formulated as a collaborative therapeutic alliance between patient, family, and health care team Implementation requires understanding and agreement between patient and care providers, and that goals and treatment plan are reasonable Comprehensive foot examination ADA Clinical Practice Guidelines. Diabetes Care 2012; 35 (Suppl 1) ADA Clinical Practice Guidelines. Diabetes Care 2012; 35 (Suppl 1) Adults aged 18 years with Diagnosed Diabetes Receiving Preventive Care Practices, United States, 2010 (Age-Adjusted) Dartmouth Hitchcock Diabetes Program 3

4 my.clevelandclinic.org/documents/outcomes/2010/outcomes medicine 2010.pdf Severe periodontitis and diabetes HbA1c 9% risk for severe periodontitis Periodontitis increases insulin resistance 2x incidence of macroalbuminuria 3x increased incidence of ESRD 3x higher risk of cardiorenal mortality 4

5 Two-way relationship Periodontitis prevalence at WDI A total of 22 pilot patients (May 2011-April 2012) were evaluable [mean HbA1c 9.0% (range, 5.3%-17.4%)] 17 (73%) had periodontitis 5 (23%) were classified as severe * [mean HbA1c 10.3% (range, 6.6%-17.4%)] 5 (23%) as moderate 5 (23%) had no periodontitis [mean HbA1c 8.7% (range, 7.2%-11.5%)] *severe periodontitis was defined as clinical attachment loss (CAL) of 5 mm (bone level >6 mm) Challenges to delivering high-value diabetes care Complex interplay of multiple organ systems Incomplete evaluations (~50%) 21 st -century medical science delivered in 19 th -century organizational structure Patient compliance (engagement) ~30% Providers from disparate disciplines and no common language Medical and dental teams rarely collaborative Clinically integrated team or collection of fragmented services? Need for measurement of full-cycle outcomes and costs No composite disease-severity staging index No adequate disease registry IT platform EHR Reframing 5

6 (DXDI ) RD: Nutritional assessment Endocrinology: Screen for HTN, dyslipidemia, nephropathy, depression Patient Clinical Pharmacist PA Care Coordinator (CoreCTA*) Optometry: Dilated & Comprehensive Eye Exam with Retinal Scan Physical Therapy: Screen for neuropathy, PAD, & functionality Initial Assessment Dental: Comprehensive Periodontal 2 D echo: Assessment Screen for structural heart disease *Core Collaborative Therapeutic Alliance PA Care Coordinator: Functions as a member of the CoreCTA to develop a care management plan based on the patient s DXDI profile and ensure the patient understands its implications, is committed to the education and other follow-up activities involved in the total care cycle. Coordinates patient navigation throughout care cycle including healthy eating habits, physical activity, medication adherence, self-management education classes, referrals, glucose selfmonitoring, and goals for HbA1c, blood pressure, and cholesterol levels. Identifies obstacles to implementing care plan Coordinates care plan with patient s PCP and provides direct patient care within the context of the integrated practice unit care team. PA Care Coordinator: Staffs and co-manages patients with WDI Clinical Pharmacist in the Diabetes Medication Management and Insulin Titration Clinic. Reviews patients records for efficient drug therapy, drug-drug interactions, adverse reactions, contraindications, allergies, and sensitivities. Follows through with resolving medication therapy issues. Enters into, and follows, data through WDI registry/ehr 6

7 A morbidly-obese 39-year-old man (BMI 37) is referred by his PCP with new diagnosis of diabetes. PMHx hypertension. Takes hydrochlorothiazide. Smokes one pack/day. Family history of type 2 diabetes and cardiovascular disease in his mother and older brother. HbA1c 8.9% BP 140/90 LDL-C 120 mg/dl Retina: dot-blot hemorrhages/cotton wool spots Oral cavity: Severe periodontitis Feet: + sensory neuropathy Functionality: modified-independent egfr: 95 ml/min/1.73 m 2 urinary albumin-creatinine ratio (ACR): 20 mg/g 2-D Echo: MAC, LV hypertrophy and LVEF 55% (DXDI ) 7

8 Metabolic & Bariatric Surgery MNT & DSME Center for Fitness and Function Endocrine & Glycemic Management Clinics CoreCTA Cardiology consult in Heart and Vascular Center Eye Care Center Dental Center Measuring Outcomes Survival Degree of health Time to health and functionality Experience and disutility of care Sustainability of health over time Long term consequences of therapy Mortality Severity of end-organ disease complications (DXDI staging) ) Functional level and degree of independency Level of satisfaction with health status Time to reaching ABC target goals Time to reaching highest functional level) Length of hospital stay, if necessary Treatment-related discomfort, complications, adverse effects, diagnostic errors, treatment errors Level of satisfaction of care Maintain functional level and ability to live independently Maintain glycemic control Maintain blood pressure <130/80 De novo end-organ disease complications Recovered end-organ disease complications Care-induced illness (e.g., hypoglycemic episodes) (DXDI ) WDI Cloud Dental Center Center for Kidney Disease Endocrine Clinic and Hypertension Diabetes Medication Management and Insulin Titration Clinic Heart and Vascular Center Eye Care Center Center for Fitness and Function Clinical Research Unit MNT & DSME ID Clinic Amputation Prevention Center 8

9 Summary 1. Organize integrated, interprofessional teams around CoreCTA. 2. PA Care Coordinator is a linchpin for the WDI integrated practice unit. 3. Stratify patients based on a composite disease-severity index. 4. Personalize care plans aligned with patient goals and based on their index profile. 5. Engage all stakeholders (patient, caregivers, providers, and payers). 6. Build and maintain an index-based disease registry IT platform. 7. Measure outcomes and cost across care cycle to keep improving. 9

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